The CMS wants help figuring out how to use new technologies like artificial intelligence to cut fraud and abuse in Medicare and Medicaid, according to a request for information released Tuesday.
The agency is asking the private sector for advice on how emerging technologies can be used to ensure proper claims payment, reduce paperwork for providers and make sure its program integrity activities are efficient. It's interested in applying new technologies to program integrity efforts for its traditional fee-for-service programs as well as value-based care.
Comments could address several of the CMS' challenges, including how to use technology to make sure it's only enrolling legitimate providers and suppliers. Currently, the agency relies on its records system, but it thinks new technology and data sources could spot problematic business relationships by automatically sifting through state and local information on business ownership and registration.
Electronic health records and chart reviews are other areas that the CMS thinks could be ripe for emerging technologies like AI and machine learning. The agency wants to automate chart documentation to prevent improper payments, a shift from how it chases down incorrect payments now.
The CMS is also concerned that its old data storage and analytics systems don't talk to each other. It is looking for ways to make them work together and make it easier for them to find and fix program integrity problems.
The agency would also like to change how it carries out Medicare claim reviews and Medicare Advantage audits. Claim reviews and MA audits are too expensive, time-consuming and burdensome because they require so much effort from providers, suppliers and payers, according to the CMS. With tools like prior authorization on hold for now, it's looking to AI and machine learning to speed up the processes.
Value-based payments could benefit from tech that prevents improper payments, finds bad actors and ensure that data is accurate and reliable, according to the CMS. In recent years, the Center for Medicare and Medicaid Innovation has rolled out new payment models that tie payments to quality, including new payment programs like the merit-based incentive payment system, accountable care organizations and bundled payments.
Those models are based on original Medicare's fee-for-service payment structure. Newer payment models like Next Generation ACOs take things a step further because they're not tied to acute medical events and pay for long-term health outcomes.
The CMS is worried that value-based payments could pose new problems like underutilization and improper risk adjustment for covered patients. New technology could bolster program integrity, especially when it comes to medical record review. Making sure that it's using high-quality data to link payments with clinical outcomes is also a top concern because the agency won't be able to check that it's paying correctly without it.
Since private payers also use value-based payments, the CMS wants to learn more about what technologies and processes they're using to ensure appropriate payment and patient care. The agency thinks it could probably use existing technology for its own value-based payment programs.
Under the Trump administration, the CMS has been focused on the adoption of new technology in the government's health insurance programs. The administration thinks health IT interoperability, open application programming interfaces, patient access to data and telehealth are vital to moving to VBPs and driving down healthcare spending.
This request for information is the latest development in the agency's drive to modernize and cut healthcare spending.